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Fortunately there is a vaccine for HPV and I would encourage everyone to consider getting it, especially barebackers. The good news from this article is that most don't progress to the more insidious cancers. The recommendations and conclusions are summed up below in the Editors' Recommendations.

MSM at High Risk for Anal Lesions But Most Won't ProgressHPV Vaccine Protection Against Anal Disease in MenFDA Panel Recommends HPV Vaccine for Anal Cancer Prevention

BRUSSELS— Anal dysplasia is frequent in HIV-positive men who have sex with men. Longer sustained control of HIV is associated with less high-grade anal intraepithelial neoplasia, according to a recent study.

"Among patients with abnormal cytology, 83% had abnormal biopsy, including half with high-grade anal intraepithelial neoplasia," said Agnès Libois, MD, from the infectious disease service at the Saint-Pierre University Hospital in Brussels.

She explained that anal cancer is caused by infection with high-risk types of the human papillomavirus (HPV) and is preceded by high-grade dysplasia. Anal cancer occurs at a younger age in people who are HIV-positive than in those who are not (about 40 vs 60 years). In HIV-positive men, the prevalence of anal HPV might be as high as 95%, whereas in heterosexual men, it is 60%.

Dr. Libois presented the study results here at the 14th European AIDS Conference.

The prospective study evaluated 425 HIV-positive men who have sex with men who underwent anal cytology screening. If the results were abnormal, patients were referred for high-resolution anoscopy and biopsy. Biopsy histologies were classified as normal or as anal neoplasia grades 1, 2, or 3, with 3 being a cancer precursor.

The screened population was 90% white, mean age was 44.5 years (range, 22 - 71 years), 85% were on antiretroviral therapy, 73% had a viral load below 50 copies/mL, and median CD4 count was 632 cells/μL. The median duration of HIV was 7.5 years, and the median time on antiretroviral drugs was 7.0 years.

Of the 382 smears of sufficient quality for analysis, 48% were abnormal, according to the modified Bethesda System — 19% were atypical squamous cells of undetermined significance, 4% were atypical squamous cells where a high-grade lesion could not be ruled out, 22% were low-grade squamous intraepithelial lesions, and 3% were high-grade squamous intraepithelial lesions.

Patients with normal cytology were more likely to have undetectable viral loads than those with abnormal cytology (82% vs 62%; P < .001), and were taking combination antiretroviral therapy for a longer period of time (111 vs 49 months; P = .002). There was no correlation between cytology and age or current or nadir CD4 count.

Of the 118 high-resolution anoscopy with biopsies performed on the 183 patients with abnormal cytology, 17% of the biopsies were normal, 33% were neoplasia 1, and 39% were neoplasia 2/3. Interestingly, the high-grade specimens fell into all 4 Bethesda System abnormal cytology categories. Neoplasia 2/3 did not correlate with age, current CD4 count, or HIV viral load.

Dr. Libois concluded that anal dysplasia and high-grade neoplasia are frequent in HIV-positive men who have sex with men, and cytology with or without biopsy is the only way to detect lesions. Normal cytology "was associated with an undetectable viral load and a longer duration of combination antiretroviral therapy," whereas the risk for neoplasia 2/3 was increased with a nadir CD4 count below 100 cells/μL and a shorter time with an undetectable viral load.

"Longer sustained HIV control was associated with less anal neoplasia 2/3," Dr. Libois said, but it is an open question whether early initiation of antiretroviral therapy decreases the incidence and prevalence of anal cancer in this population.

She noted that most studies have shown that combination antiretroviral therapy has no effect on anal dysplasia, but the duration of therapy was often 2 years or less. Some recent studies with a longer duration of therapy have shown a beneficial effect, and one showed that a longer time with an undetectable viral load and a higher nadir CD4 count were associated with a lower incidence of anal squamous cell cancer.

These researchers "are essentially reporting the exact same prevalence and the high level of HPV anal intraepithelial neoplasia" as seen in the Chelsea and Westminster cohort study from London (Curr Opin HIV AIDS. 2009;4:64-67), said session chair Fiona Mulcahy, MD, from St. James's Hospital of Trinity College in Dublin, Ireland.

"You could spend your whole life in a clinic doing anoscopy and doing high-resolution anoscopy and biopsy, but actually there are no clear patterns of management for advanced disease. Our problem is that with anal intraepithelial neoplasia, there's no specific intervention that seems to be curative because of the recurrence rates," she told Medscape Medical News.

She said that many studies, but not all, have shown that CD4 cell nadir seems to have an impact. In addition, as Dr. Libois's team showed, the longer patients are on treatment, the less likely they are to have high-grade lesions. However, there are conflicting results on this point. Anal neoplasia "seems to be advancing irrespective of our control, which is also a bit of a worry," Dr. Mulcahy said.

As the data stand, she said, they do not push her to start treating everyone early with antiretroviral therapy.

There was no commercial funding for the study. Dr. Libois reports no relevant financial relationships. Dr. Mulcahy reports work with AbbVie, BMS, Merck, and GSK, and Gilead.

It seems bug is saying that anal cancer is not linked with bareback anal sex. Perhaps I misunderstanding him. But then other reports seem to indicate that the transference of the HPV to the anal mucosa does show a link for this specific form of cancer, thus, the markedly higher rate of this in MSM.

I don't know much about this but would appreciate information. I did have 2 small anal warts and so went in for an HRA. It was not a pleasant experience, but was not horrible. The doc did snip off one of the warts, and biopsied it. Everything has come back negative and he said I could come back every 2 years for another HRA for peace of mind if I wanted to.

that is what I thought also, but from what I am gathering, bug and emerald do not agree with that. (?) I may be misreading them. I do know bug is very meticulous in what he posts, and I place a lot of attention on his perspective.

I also am wondering if there is benefit for us older guys who are still sexually active to get the HPV vaccine if indeed it will at least work for some strains, etc, that we may not have been exposed to. Would it hurt to get it? Could it help?

Anal sex may be the main route, but it is not the only route. HPV can be transferred via skin-to-skin contact alone. Thus, digital contact and oral contact can transfer HPV. It can even be transferred without direct contact of any kind with the infected partner: If an uninfected person touches an infected part of a partner and then touches himself or herself, HPV can be transferred.

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"No one will ever be free so long as there are pestilences."--Albert Camus, "The Plague"

"Mankind can never be free until the last brick in the last church falls on the head of the last priest."--Voltaire

that is what I thought also, but from what I am gathering, bug and emerald do not agree with that. (?) I may be misreading them. I do know bug is very meticulous in what he posts, and I place a lot of attention on his perspective.

I also am wondering if there is benefit for us older guys who are still sexually active to get the HPV vaccine if indeed it will at least work for some strains, etc, that we may not have been exposed to. Would it hurt to get it? Could it help?

The VAST majority of people who have had more than three sexual partners already have been exposed to HPV. It's literally omnipresent. The vaccine might (might!) be worthwhile if given to teens who have not become sexually active, but even then there is controversy regarding it's efficacy.

IMHO it is a great deal of manufactured hysteria with little real scientific evidence to point to this "pandemic."

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"Many people, especially in the gay community, turn to oral sex as a safer alternative in the age of AIDS. And with HIV rates rising, people need to remember that oral sex is safer sex. It's a reasonable alternative."

"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

I'm still confused. Is the vaccine still effective against anal cancer if you've already been exposed to HPV?

The vaccine is approved for young adults and teens to take before they get exposed. This is the only group it is approved for.

Some doctors may prescribe it off label for people who are older and even those already infected with HPV with dysplasia on an experimental basis.

For full disclosure: my doctor gave me the full 3 shot HPV vaccine series after I had my first pap and HRA that showed high grade cells. Besides the shot giving me a super headache each time I still had to go though all the regular treatments (and still am years later). Can't say the vaccine did much for me although who knows.

I was pretty creeped out by it too. Maybe he chose his words to grab people's attention? Kinda like tabloid newspaper headlines.

Be careful what you wish for

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"Many people, especially in the gay community, turn to oral sex as a safer alternative in the age of AIDS. And with HIV rates rising, people need to remember that oral sex is safer sex. It's a reasonable alternative."

Well, as mentioned, 60% of heterosexual men have anal HPV, so I doubt that anal sex is the main route... Maybe it is the main route only for the strains that are related to a high risk of anal cancer?

But there is something I don't get in this sentence:"In HIV-positive men, the prevalence of anal HPV might be as high as 95%, whereas in heterosexual men, it is 60%."Why are "heterosexual men" presented as the opposite of "HIV-positive men"?

But there is something I don't get in this sentence:"In HIV-positive men, the prevalence of anal HPV might be as high as 95%, whereas in heterosexual men, it is 60%."Why are "heterosexual men" presented as the opposite of "HIV-positive men"?

Well I guess its just incomplete writing. Sloppy. They didn't take the time to write the complete description of each sample. But one time they do: 425 HIV-positive men who have sex with menSo every subsequent mention of "HIV-positive men" in the article refers to HIV+ gay men.

The authors were sloppy not to specify if the comparison sample of "Heterosexual Men" is HIV+ and HIV- or, as we can assume by the context of the writing, ONLY HIV- heterosexual men.

Its sloppy but I don't think they are presented as "opposites" per say. Just as comparison groups.

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“From each, according to his ability; to each, according to his need” 1875 K Marx

Well, as mentioned, 60% of heterosexual men have anal HPV, so I doubt that anal sex is the main route

I apologize for being extremely careless with my terminology. When I used "anal sex" in that context I meant the insertion of the penis into the anus. I was trying to explain why, lacking that action, HPV can still be transmitted.

Logged

"No one will ever be free so long as there are pestilences."--Albert Camus, "The Plague"

"Mankind can never be free until the last brick in the last church falls on the head of the last priest."--Voltaire

When I see sloppy terminology allowed publication, it calls into question the entire peer-review process that allowed the study publication and gave it credence.

Logged

"Many people, especially in the gay community, turn to oral sex as a safer alternative in the age of AIDS. And with HIV rates rising, people need to remember that oral sex is safer sex. It's a reasonable alternative."